NCC241461_FRO Submitted_20240513

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name: Meadow Lane Lots 20-34
*If this project involves American Rescue Plan Act(ARPA)funds,list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Davidson City or Township: Thomasville
Highway/Street: Meadow Lane Latitude: 35.841500 Longitude:-80.078000
3. Approximate date land-disturbing activity will commence: 5/31/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.70
6. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Example: 8.10-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Roy Alley E-mail Address: [e-mail]
Phone: [phone] Mobile:
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Foundation Home Builders LLC [e-mail] 3363386408
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
415 Pisgah Greensboro NC 27455 415 Pisgah Church Greensboro NC 27455
Church Road Road

Part B.
1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the
name(s)of the owner(s)may be listed as the financially responsible party(ies).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Foundation Home Builders LLC [e-mail] 3363386408
Physical Address Mailing Address
Street 1 City _ State Zip Street 1 City State Zip
415 Pisgah Greensboro NC 27455 415 Pisgah Greensboro NC 27455
Church Road Church Road
Additional Financially Responsible Parties
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the
landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent who is registered on the NC Secretary of State business registry:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water
2. Was Express Review Requested: No
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
[tvY1`t H OC..(DC' L.
1. Project Name !AP_.cictiuq,� LOon �f�i�Ct=M`a C4/•;0 /1-tUO\CO it0591-1-(006kt:C45,
*If this project involves American Rescue Plan Act(ARPA) funds, list he Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: CountyltWviCk5C,,-\ City or Township Tltic, , ,l(C
Highway/Street Net LA Lot - Latitude degrees)(decimal de rees LongitUde(decimaf degrees)
3. Approximate date land-disturbing activity will commence: (St(v*
4. Purpose of development(residential, commercial, industrial, institutional, etc.): 1rc5t.cae..-v{,-«t
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): ite 1+4 b
6. Amount of fee enclosed: $ L cC.e) . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes RI" Enclosed 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name � 1 ��r
`� E-mail Address YIN 6)11 ix:.Uric . cc.1,1
Phone: Office# •laMO Mobile# Ng: 33�' -
9. Landowner(s)of Record (attach accompanied page to list additional owners):
FOMAct;. +cvt lrNa.i( , ev-_, LLC ;54.r Si? (vg U 3 33 33 toga
Name Phone: Office# Mobile#
//
Current Mailing Address Current Street Address
Gre Cd151Jt'V1.r f L 2`1` 6jYY e f)L
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
tk..arkt-t,'lc

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
vtovic LJrleItte, Lit v(. 4�i+1C� 'Ya?L�vutl (fume (e'V�j.
Company Name E-mail Address
4 1C i r' l5t•�1cL\ Ck.t.vcji&4 `k-S j ISCi: V{ it toot
Current Wiling Address Current Street Address
Cle cit49vvv., & e 615be N L Z 7 i(.4 ?-
City State Zip City State Zip
Phone: Office# 3 S t4'4DV Mobile# 3ti' S 3 S. 14'
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
yes/AUe.4,1t'TQ,u4A6.f c..i e 144ev5• u ►v.
Name of Registered Agent E-mail Address
11(C 1215ytA, nuvi_kk ec . 1*35 �jb+.. ()to c_v 4- - e_ek, 1O5
Current Mailing Address Current Street Address
CyrCZ+15bt)✓\/ AIL Z }-4 , , Cr'1�ih4�. 4 I`) 211z
City State Zip City State Zip
Phone: Office# S 3 - +;04 Mobile# 5 - `(t) g
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent 9 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership,or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Yo1 f= AU d r�
1"'U;<AC�.c: t'fir'
C Ty e or print name Title or Authdrity
•
ignature O Z'-A
Date
I, s__)c'ccp; �Yl n
�'�/�� - 1 c; �L.L._, a Notary Public of the County of 6;0.\ �or-€1
State of North Carolina, hereby certify that R0> V A ( 1 apeared
before me this day and being duly sworn acknowledged that the ab a form was executed by him/her.
Witness my hand and notarial seal, this ,2) day of '-rAc_ , 20 a`-c
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NOTARY rn;"
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